Key studies

ImproveCare

ImproveCare - The management of clinical uncertainty in hospital settings

This study is a collaboration between King’s College London and University of Cambridge led by Dr Jonathan Koffman. ImproveCare is a feasibility cluster randomised controlled trial comparing the AMBER care bundle (ACB) to usual care.

What is ImproveCare?

The AMBER care bundle (which stands for Assessment, Management, Best Practice, Engagement, and Recovery uncertain) is a complex intervention that has been developed to better care for hospital patients whose situations are clinically uncertain and are at risk of dying during their hospital stay despite treatment. For these patients staff develop a plan with patients (where possible) and their family that documents what is important to them. The patient’s status and their wishes are revisited daily. We have conducted a small study to explore the AMBER care bundle and observed some benefits and areas of concern (link to this study can be found here).

Before more hospitals use the ACB it is important to rigorously study whether the ACB improves care, or not. In this study, AMBER care will be compared with usual care. This study aims to help us know if can recruit enough people, that the outcomes we use reflect what patients and families feel are important, whether it represents good value for money, and that the study procedures are workable. We will collect information from patients and their families at different time points. Open interviews with patients, caregivers and staff will help us better understand what they value about the AMBER Care bundle and how it works.

Why the ImproveCare is needed now?

500,000 people die per year in the UK; half of all deaths occur in hospital. Most people prefer to die at home but this does not happen because there is little discussion between patients, families, and health care professionals about what they want. It is made worse when it is difficult for health care staff to identify patients, whose situation is clinically uncertain. This is an area of care many professionals feel less confident in their knowledge/skills. Recent reports have highlighted what can go wrong in the presence of clinical uncertainty and at the end of life; for example treatment that is aggressive with little benefit can be administered to the patients. This could be devastating for patients and families.

The AMBER care bundle has been identified by NHS England as one of five key enablers to Transform End of Life Care in Acute Hospitals and it is currently being used in approximately 40 hospitals In England, including district general hospitals. It is essential that a clinical trial of the AMBER care bundle takes place to quantify patient, clinician and health system benefits, and that any harms are understood and managed prior to rollout of the care bundle to more hospitals.

Now, more than ever (with ageing populations and increasing numbers of people dying from cancer and non-malignant conditions), health care systems should provide every patient and their family with a dignified death. Facing deteriorating health and uncertain recovery is distressing for patients who may be dying, and their families. This is particularly due to the frequent, possibly unnecessary, hospital admissions during the last year of life. In England patients currently spend an average of 29.7 days of their last 12 months in hospital. This is often not wanted by patients and families, and is costly for health services and for society. These concerns are endorsed by the NHS Commissioning Framework which includes two outcomes to improve care for people at the end of life; the proportion of patients who die in their preferred place of death; and bereaved relatives’ experiences of care.

What does this study involve?

The study will run at four study sites in England and will be coordinated by the research team based at the Cicely Saunders Institute, King’s College London. All the study sites are district general hospitals and the study wards are general medical ward. Recruitment to the study will begin in April 2017. The two sites have been allocated at random for patients to be cared for using the AMBER care bundle, the other two sites will carry on providing usual care for this group of patients. Patients will be asked to complete a questionnaire at the three time points: baseline, 3 to 5 days after and 10-15 days after the completion of the first questionnaire. For a group of patients and their relatives short interviews will be held regarding the patient’s illness and care. Additionally, we will conduct focus groups with the healthcare professionals, observe their multidisciplinary team meetings and ask them to fill in a questionnaire about the care provided at the ward at the study sites. We will also send out a post-bereavement survey to the relatives of patients who have lost their lives during or shortly after the study.